Report on Medicaid Managed Care Provider Network Adequacy...MCO reporting on time required to make...

Report on Medicaid

Managed Care

Provider Network

Adequacy

As Required by

Senate Bill 760, 84th

Legislature, Regular Session,

2015

Health and Human Services

Commission

December 2018

i

Table of Contents

Executive Summary ............................................................................. 1

1. Introduction .................................................................................... 3

2. Background ..................................................................................... 4 Medicaid Managed Care ....................................................................... 4 Network Adequacy Initiatives ............................................................... 5

3. MCO Network Oversight ................................................................ 14 Appointment Availability .....................................................................14

Prior Authorization Wait Times ............................................................22 Provider Ratios ..................................................................................23 MCO Network Analysis .......................................................................28

4. Conclusion ..................................................................................... 35

List of Acronyms ................................................................................ 37

Appendix A. County Designations ..................................................... A-1

Appendix B. MCO Prior Authorization Reporting ................................ B-1

Appendix C. Provider Ratios .............................................................. C-1

Appendix D. MCO Network Analysis - PCPs and Main Dentists ......... D-1

Appendix E. MCO Network Analysis - Specialists ............................... E-1

1

Executive Summary

The Texas Medicaid program provides healthcare and long-term services and

supports to more than four million individuals, the majority of whom receive

services through managed care.1 Medicaid managed care programs provide a wide

array of acute health care services (primary, specialty and behavioral health care,

pharmacy, dental and diagnostic services) and long-term services and supports

(nursing, home health care, therapy services, home and community-based services,

nursing facility and attendant care). To provide these services to Medicaid

members, the Health and Human Services Commission (HHSC) contracts with

managed care organizations (MCOs) and dental managed care organizations

(DMOs), to ensure individuals receive the health care they need.

To determine whether MCOs and DMOs have adequate provider networks, HHSC

tracks timeliness of care through annual surveys, monitors member and provider

complaints,2 analyzes geo-mapping reports to measure the distance and travel time

between providers' geographic locations and members' residences, and monitors

utilization of out-of-network providers.

Senate Bill (S.B.) 760, 84th Legislature, Regular Session, 2015, requires HHSC to

report to the Legislature on access to providers in Medicaid managed care

networks, and MCO compliance with contractual obligations related to provider

access standards. Specifically, the report requires:

● A compilation and analysis of information reported by MCOs to HHSC on MCO

compliance with Medicaid managed care network adequacy requirements;

1 Texas Health and Human Services Commission, Health Care Statistics. Medicaid and CHIP

Enrollment. https://hhs.texas.gov/about-hhs/records-statistics/data-statistics/healthcare-

statistics.

2 HHSC manages complaints or inquiries received from Medicaid providers, members, state

agencies, or government officials. Information received provides insight into trends in

Medicaid managed care programs which, if not resolved in a timely manner, can result in

corrective action against an MCO or a DMO.

2

● Data on MCOs’ average length of time for approving or denying a request for

prior authorization of services, and between approving the request and

initiation of service;

● A description and analysis of results from HHSC’s process for monitoring

MCOs; and

● Information on provider-to-recipient ratios in an MCO's provider network,

including benchmark ratios to indicate whether there are deficiencies in a

given network.

The results of these monitoring initiatives, detailed in Section 3, show MCOs are

performing well in meeting requirements related to providing access to preventive

care, with nearly all MCOs compliant with access standards for primary care

providers (PCPs) and main dentists for all Medicaid programs. However, specialty

provider shortages, particularly in rural areas of the state, continue to present

challenges to member access.

MCO reporting on time required to make prior authorization decisions varied widely.

For specialty care in the STAR program, the average time for an MCO’s prior

authorization decision ranged from 0 days to 6 days for plans that require prior

authorization, and the average time from MCO approval to service initiation ranged

from 0 days to 40 days among plans that require prior authorization.

A 2015 study to examine appointment availability for behavioral health and

obstetrics/gynecology (OB/GYN) visits, based on a limited sample of providers,

showed MCOs did not meet contractually required access standards. The same

study conducted in 2016 showed overall improvement in behavioral health but less

favorable performance for high-risk prenatal care.

Healthcare provider shortages are not exclusive to Medicaid. Statewide provider

ratios for the general population are in some cases less favorable than ratios

reported for the Medicaid population. Statewide, the ratio of licensed psychiatrists

to the general population is 1:13,258 compared to a ratio of 1:2,513 serving

Medicaid. Even so, access to behavioral health services in Medicaid remains a focus.

While none of these indicators alone provides a full and accurate measure of

network adequacy, combined they help HHSC assess the adequacy of MCO or DMO

provider networks and their performance in meeting contractual obligations. This

report contains a comprehensive account of MCO compliance with contractual

obligations related to network adequacy and HHSC’s continued efforts to ensure

member access to a choice of quality providers.

3

1. Introduction

In 2015, the 84th Legislature, Regular Session, adopted S.B. 760, which modified

Texas Government Code 533.005 to provide the state with additional tools for

ensuring network adequacy in Texas Medicaid managed care. The bill directs HHSC

to develop requirements for MCOs to:

● Pay liquidated damages for failing to comply with minimum network access

standards;

● Establish an expedited credentialing process for certain provider types

identified by HHSC;

● Regularly update and publish provider directories on MCO and DMO websites;

and

● Send paper copies of provider directories to all STAR+PLUS and STAR Kids

members, unless these members opt-out, and to members of other Medicaid

managed care programs only upon request.

In response to the requirements of S.B. 760, HHSC worked extensively with

stakeholders, including member advocates, provider groups, MCOs and DMOs, to

implement several key initiatives, including:

● Updating requirements for MCO provider directories, including a requirement

that all directories be available online, updated weekly, and searchable;

● Developing new distance and travel time standards for certain provider

types, taking into account geographic area and managed care program

service requirements;

● Updating expedited credentialing standards to decrease the time before a

provider may be reimbursed for services and to allow MCOs and DMOs to

more quickly address gaps in network coverage; and

● Enhancing MCO reporting and HHSC oversight to ensure compliance with all

network adequacy standards.

These initiatives are part of HHSC’s ongoing commitment to improving access to

quality care for Medicaid members, and ensuring MCO and DMO accountability for

health care service delivery. HHSC’s current network adequacy contractual

requirements and monitoring processes provide the framework for ensuring access

to care for nearly four million Medicaid members statewide.

4

2. Background

Medicaid Managed Care

In Texas, 93 percent of individuals enrolled in the state’s Medicaid program receive

services through managed care. Under the managed care model, the state

contracts with MCOs to provide members with an array of covered services and

supports. HHSC pays MCOs and DMOs a monthly amount per enrolled member to

coordinate and reimburse providers for services to Medicaid members enrolled in

their health and dental plans. MCOs contract with providers, including primary care

physicians, specialty care, and behavioral health providers. These providers make

up the MCOs “network.” Sufficient provider networks ensure members have timely

access to, and a choice of, health care providers and services covered by the

Medicaid program.

HHSC administers and provides oversight of the state’s Medicaid program in

accordance with state and federal requirements. At the federal level, the Social

Security Act3 and Code of Federal Regulations4 require states to ensure that MCOs

demonstrate the capacity to serve expected enrollment in the MCOs’ service areas.5

The regulations include requirements for an appropriate "range of services and

access to preventive and primary care services," with a "sufficient number, mix,

and geographic distribution of providers of services." Generally, each state has

flexibility to determine how to meet the federal requirements.

At the state level, HHSC establishes managed care contract requirements in

accordance with Texas Department of Insurance (TDI) rules and regulations, and

federal and state Medicaid rules. HHSC requirements are generally consistent with,

or more stringent than, federal or TDI requirements.

3 SSA §1932(b) (5), Demonstration of Adequate Capacity and Services.

4 42 CFR §438.206 Availability of Services, §438.207 Assurances of Adequate Capacity and

Services.

5 Service area means all the counties, as applicable to each managed care program, for

which an MCO has been selected to provide MCO services.

5

In Texas, Medicaid managed care includes the STAR, STAR+PLUS, STAR Kids, STAR

Health programs, and Children’s Medicaid Dental Services program for individuals

age 20 and younger. Eighteen MCOs and two DMOs deliver services across the

state, operating in distinct geographic locations known as service delivery areas

(SDAs). Each SDA has multiple counties. HHSC requires each MCO to ensure the

delivery of services and supports for each of its members on a county-by-county

basis.6 In accordance with state and federal regulations, HHSC is responsible for

ensuring each MCO maintains the required provider networks necessary to allow

members in all regions of the state to have timely and reasonable access to

covered services.

Network Adequacy Initiatives

Time and Distance Standards

As part of its efforts to implement the requirements of S.B. 760, HHSC established

an internal workgroup to address network adequacy issues in Medicaid managed

care. A key initiative of the workgroup was to develop the provider network travel

time and distance standards required by S.B. 760, and the protocols for analyzing

MCO and DMO compliance with these new standards. HHSC developed the

standards in close coordination with external stakeholders. In March 2017, HHSC

amended its managed care contracts to include new distance and travel time

standards for specific provider types and county designations. See Appendix A for

county designations.

In developing the revised network standards, HHSC considered distances and travel

times required for Medicare Advantage plans.7 When appropriate, HHSC adopted

the network standards used by Medicare. In some cases, Medicare standards

conflicted with existing provider standards required by TDI, in which case HHSC

deferred to TDI standards. For example, TDI rules, 28 TAC § 11.1607(h), require

access to specialty care within 75 miles, while Medicare Advantage allows longer

6 In Texas, the Texas Department of Insurance licenses managed care entities. The license

specifies in which areas of the state the entity can operate.

7 Medicare Advantage plans provide managed care services for Medicare recipients.

Medicare established distance and travel time for Medicare services. Stakeholders suggested

Medicaid consider these as a starting point for distance and travel time, and consider county

level designations since managed care plans in Texas were already familiar with them.

https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=28&pt=1&ch=11&rl=1607

6

travel distances in some rural counties; therefore, in order to comply with TDI

rules, HHSC Medicaid managed care standards for specialty care do not exceed 75

miles. Table 1 below outlines the distance and travel times required for MCO

provider networks beginning in March 2017, and Table 2 outlines additional network

standards added to Medicaid managed care contracts in September 2018.

Table 1: Medicaid Managed Care Network Access Distances and Travel Times -

March 2017 Contract Amendments

Provider types/services Programs Distance and Travel Times8

Behavioral Health-

Outpatient Care

STAR, STAR Health, STAR

Kids, STAR+PLUS

Metro: 30 miles, 45 minutes

Micro: 30 miles, 45 minutes

Rural: 75 miles, 90 minutes

Cardiology or

Cardiovascular Disease


Kids, STAR+PLUS




Endodontist, Orthodontist,

and Prosthodontist

Children’s Medicaid Dental,

STAR Health

75 miles, 90 minutes

General Surgeon STAR, STAR Health, STAR

Kids, STAR+PLUS




Hospital- Acute Care STAR, STAR Health, STAR

Kids, STAR+PLUS

30 miles, 45 minutes

Main Dentist Children’s Medicaid Dental,

STAR Health




Obstetrics or Gynecology STAR, STAR Health, STAR

Kids, STAR+PLUS




Occupational, Physical, or

Speech Therapy


Kids, STAR+PLUS




Ophthalmology STAR, STAR Health, STAR

Kids, STAR+PLUS




8 Metro, Micro, and Rural refer to county designation. These are based on population and

population density. See Appendix A, which provides a map and lists each county by

designation.

7

Provider types/services Programs Distance and Travel Times8

Orthopedics STAR, STAR Health, STAR

Kids, STAR+PLUS




Otolaryngology (ENT) STAR, STAR Health, STAR

Kids, STAR+PLUS




Pediatric Dental Children’s Medicaid Dental,

STAR Health




Pediatric Sub-Specialty STAR, STAR Health, STAR

Kids




Prenatal Care STAR, STAR Health, STAR

Kids, STAR+PLUS




Primary Care STAR, STAR Health, STAR

Kids, STAR+PLUS




Psychiatry STAR, STAR Health, STAR

Kids, STAR+PLUS




Urology STAR, STAR Health, STAR

Kids, STAR+PLUS




Table 2: Medicaid Managed Care Network Access Requirements - September 2018

Contract Amendments

Provider types/services Programs Measure

Audiology Services (includes

hearing aids)

STAR, STAR Health,

STAR Kids, STAR+PLUS




Mental Health Rehabilitative

Services

STAR, STAR Health,





Mental Health Targeted Case

Management

STAR, STAR Health,





8

Provider types/services Programs Measure

Pharmacy9 STAR, STAR Health,





Pharmacy - Medicaid Rural

Service Area (MRSA)10

STAR, STAR Health,





Skilled nursing STAR+PLUS Choice of two in county


Speech Therapy -in home

STAR Health, STAR

Kids, STAR+PLUS

Choice of two in county

Attendant Care STAR Health, STAR

Kids, STAR+PLUS


CFC Habilitation STAR Health, STAR

Kids, STAR+PLUS


Consumer Directed Services STAR Health, STAR

Kids, STAR+PLUS

Choice of two financial

management service agencies

Private Duty Nursing STAR Health, STAR

Kids


Assisted Living Facility STAR+PLUS Metro: 30 miles, 45 minutes



Nursing Facility STAR+PLUS Choice within 75 miles

Compliance Monitoring

Managed care contracts require MCOs and DMOs to ensure at least 90 percent of

members, unless otherwise specified, have access to a choice of PCPs and specialty

9 Compliance threshold for Pharmacy is 75 percent of members in Metro counties; 55

percent in Micro; and 90 percent in Rural.

10 Compliance threshold Pharmacy in MRSA is 80 percent of members in Metro counties; 75

percent in Micro; and 90 percent in Rural.

9

providers within a specified distance or travel time.11 In order to allow MCOs time to

fully implement the revised network access standards, the 90 percent compliance

threshold was implemented in phases. Beginning March 2017, upon adoption of the

revised standards, HHSC established an initial compliance threshold of 75 percent.

Effective September 1, 2018, HHSC began monitoring compliance based on the

required 90 compliance threshold. The required distance and travel time standards

vary by provider and county type.

Each quarter, HHSC analyzes provider network access for each Medicaid managed

care program, and for each participating MCO and DMO. The analysis assesses the

percentage of each managed care plan’s members, for each provider or service

type, with at least two providers within the maximum distance from the member’s

residence (based on Medicaid enrollment files). MCOs and DMOs that do not meet

the minimum established percentage for members within the required distance for

each provider or service type, may be subject to contract remedies including

corrective action plans (CAPs) and/or liquidated damages. In addition, once a year

HHSC will calculate MCO and DMO compliance with established travel time

standards, for which MCOs may also be assessed contract remedies for non-

compliance.

As part of the analysis to assess MCO compliance with network requirements, a

subset of the data included on MCO and DMO provider files is submitted to HHSC’s

enrollment broker for validation. Once the validation process is completed, HHSC

removes providers whose addresses cannot be verified, or geocoded, from the file.

HHSC then produces ‘geomap’ reports by county, which plot each MCO’s network

providers against its enrolled members, allowing HHSC to determine member

proximity to network providers.12 The criteria for analysis is adjusted as appropriate

11 Initial compliance with updated time and distance standards was based on at least 75

percent of members in an MCO’s plan. Effective September 1, 2018, the compliance

threshold increased to 90 percent of the MCO’s membership.

12 HHSC uses the following software to develop geo-mapping reports:

1. ArcGIS Desktop, including the Spatial Analyst and Network Analyst extensions, which

support geo-distance and travel time analysis, respectively.

2. 'R' - an open-source statistical analysis program, which utilizes a geosphere package

for conducting geo-distance analysis. This program runs the same geo-distance

functions utilized in ArcGIS to calculate distance between geographical points.

10

for managed care program, age, and gender (e.g., males are not mapped to

gynecologists, adults are not mapped to pediatricians, and STAR is not assessed for

LTSS). See Table 3 for additional detail on program assessment.

Table 3: Medicaid Managed Care Age and Gender Specifications

Provider types/services Managed Care Programs Age Gender

Audiology Services STAR, STAR Health, STAR

Kids, STAR+PLUS

All All

Behavioral Health-Outpatient

Care


Kids, STAR+PLUS

All All

Cardiology or Cardiovascular

Disease


Kids, STAR+PLUS

All All

Endodontist, Orthodontist,

and Prosthodontist

Children’s Medicaid, STAR

Health

20 and

younger

All

General Surgeon STAR, STAR Health, STAR

Kids, STAR+PLUS

All All

Hospital- Acute Care STAR, STAR Health, STAR

Kids, STAR+PLUS

All All

Main Dentist Children’s Medicaid, STAR

Health

20 and

younger

All

Mental Health Rehabilitative

Services


Kids, STAR+PLUS

All All

Mental Health Targeted Case

Management


Kids, STAR+PLUS

All All

Obstetrics or Gynecology STAR, STAR Health, STAR

Kids, STAR+PLUS

12-64

years

Female


Speech Therapy


Kids, STAR+PLUS

All All

Ophthalmology STAR, STAR Health, STAR

Kids, STAR+PLUS

All All

Orthopedics STAR, STAR Health, STAR

Kids, STAR+PLUS

All All

3. StreetMap Premium for ArcGIS, which works within the ArcGIS Desktop program,

and is used for geo-coding addresses.

11

Provider types/services Managed Care Programs Age Gender

Otolaryngology (ENT) STAR, STAR Health, STAR

Kids, STAR+PLUS

All All

Pediatric Dental Children’s Medicaid, STAR

Health

20 and

younger

All

Pediatric Sub-Specialty STAR, STAR Health, STAR

Kids

17 and

younger

All

Pharmacy STAR, STAR Health, STAR

Kids, STAR+PLUS,

All All

Prenatal Care STAR, STAR Health, STAR

Kids, STAR+PLUS

15-44

years

Female

Primary Care STAR, STAR Health, STAR

Kids, STAR+PLUS

All All

Psychiatry STAR, STAR Health, STAR

Kids, STAR+PLUS

All All

Urology STAR, STAR Health, STAR

Kids, STAR+PLUS

All All

The geomaps allow HHSC to determine, for each MCO, the extent to which the

MCO’s members in each county have access to a choice of providers for covered

services. HHSC also uses these reports to assess MCO compliance with

contractually required network adequacy standards. Failure to comply with contract

requirements results in the assessment of a CAP requiring the MCO to take

corrective action to ensure future compliance with program requirements.

Depending on the frequency and severity of non-compliance, an MCO may also be

subject to liquidated damages.

Provider Directories

S.B. 760 requires MCOs to publish provider directories online and update them at

least monthly. The bill also requires MCOs to provide paper directories to members

upon request. Members in the STAR+PLUS and STAR Kids programs receive a

paper directory, unless they opt-out from receiving one. In response to S.B. 760,

HHSC amended its managed contract requirements to include these requirements,

and additionally ensure online directories include the following:

● Weekly updates;

● Mobile-device accessibility; and

● Search functions.

12

Expedited Credentialing

S.B. 760 requires MCOs and DMOs participating in the Texas Medicaid program to

establish an expedited credentialing process to allow applicant providers to serve

Medicaid recipients on a provisional basis and be reimbursed for services while their

credentialing application is undergoing review. This process helps to decrease the

time before a provider may be reimbursed for services, and allows MCOs and DMOs

to more quickly address gaps in network coverage. S.B. 760 and TDI regulations

require specific criteria before expedited credentialing provisions apply. In order to

qualify for expedited credentialing, an applicant provider must:

● Be a member of an established group that has a contract with an MCO or

DMO;

● Be enrolled in Texas Medicaid; and

● Submit all documentation or other information the MCO or DMO requires in

order to begin the credentialing process.

Once a provider meets these requirements, the MCO or DMO, for reimbursement

purposes only, recognizes the applicant provider as a network provider. This allows

the provider to be reimbursed for services on a provisional basis until the full

credentialing process is completed. MCOs and DMOs must begin processing claims

from these providers within 30 calendar days after receipt of a complete

application.13

S.B. 760 requires HHSC to determine the types of providers for which MCO must

establish an expedited credentialing process. Prior to S.B. 760, HHSC enforced TDI

standards requiring an expedited credentialing process for physicians, podiatrists,

and therapeutic optometrists. In response to S.B. 760, HHSC added dentists, dental

specialists, licensed clinical social workers, and nursing facilities undergoing a

change of ownership to the list of providers eligible for expedited credentialing. To

address the behavioral health care provider shortage in Texas Medicaid, HHSC also

13 S.B. 200, 84th Legislature, Regular Session, 2015, authorized the adoption of a

Credentialing Verification Organization (CVO) model to streamline the provider credentialing

process. The bill allowed the Texas Medical Association and Texas Association of Health

Plans to contract with a third party CVO to process provider applications for credentialing

with Medicaid MCOs. All Medicaid provider types are credentialed through the CVO with the

exception of DMOs and providers who are currently credentialed through a delegation

process, such as pharmacy providers.

13

made licensed professional counselors, licensed marriage and family therapists, and

psychologists eligible for expedited credentialing effective March 1, 2017.

14

3. MCO Network Oversight

Appointment Availability

S.B. 760 directed HHSC to establish and implement a process for direct monitoring

of an MCO's provider network, including the length of time a recipient must wait

between scheduling an appointment with and receiving treatment from a provider.

To fulfill this direction, HHSC contracted with its external quality review

organization (EQRO) to implement an appointment availability study to analyze

MCO compliance with appointment access standards specified in Section 8.1.3 of

the managed care contracts, which outlines MCO requirements for ensuring

members have timely access to covered services.

Standards

Access to care includes the ability to obtain appointments for primary and specialist

care within a reasonable amount of time. HHSC managed care contracts outline

MCO provider network standards for timely appointments and the availability of

specialist appointments without referrals. Table 4 below shows the appointment

wait time standards included in the managed care contracts and used in the HHSC

appointment availability studies.

Table 4: Appointment Standards Defined in Managed Care Contracts

Level/Type of Care Time to Treatment

Urgent Care (child and adult) Within twenty-four (24) hours

Routine Primary Care (child and

adult)

Within fourteen (14)

calendar days

Preventive Health Services for

New Child Members

No later than ninety (90) calendar days of

enrollment (for STAR Health, the requirement is

30 days)

Initial Outpatient Behavioral

Health Visits (child and adult)

Within fourteen (14) calendar days

Preventive Health Services for

Adults

Within ninety (90) calendar days

15

Level/Type of Care Time to Treatment

Prenatal Care (not high-risk) Within fourteen (14) calendar days

Prenatal Care (high risk) Within five (5) calendar days

Prenatal Care (new member in 3rd

trimester)

Within five (5) calendar days

Vision Care (ophthalmology,

therapeutic optometry)

None indicated (“Access without primary care

provider referral”)

Methodology

For the appointment availability study, the EQRO uses a secret shopper

methodology to examine member experience in scheduling appointments. The

study is comprised of four ”sub-studies” covering the following areas: prenatal care

(also referred to as OB/GYN), PCP, vision, and behavioral health. HHSC began the

studies in 2015, with initial results used to develop MCO strategies for addressing

excessive appointment wait times and noncompliance with vision referral

standards.14 In the 2016 study, an MCO’s failure to meet required standards

resulted in the issuance of a CAP. In 2018, MCOs failing to meet established

minimum standards for compliance will be subject to CAPs and may be assessed

liquidated damages.

Due to the secret shopper methodology, HHSC is not able to include specialists in

the appointment availability study since specialists generally require a referral.

Instead, HHSC worked with its EQRO to develop a PCP referral study, which asks

PCPs to provide information on challenges experienced in referring members for

specialty care. The 2016 PCP referral study indicated PCPs encountered the most

challenges in obtaining referrals for behavioral health services.

Study Schedule

The EQRO conducts the appointment accessibility studies to evaluate MCO

compliance with contractual appointment availability standards, following the

schedule below. The EQRO conducted the first study in 2015, with a follow-up study

14 Vision care should be available without a PCP referral.

16

in 2016. The 2016 study was extended to cover two contract years (2016-2017).

The 2018 study will also cover two contract years (2018-2019).

2015 Appointment Availability Study15

● Prenatal - STAR17

● Vision - STAR, STAR+PLUS

● Primary Care - STAR, STAR+PLUS

● Behavioral Health - STAR, STAR+PLUS

2016 Appointment Availability Study


● Vision - STAR, STAR+PLUS

● Primary Care - STAR, STAR+PLUS

● Behavioral Health - STAR, STAR+PLUS

2018 Appointment Availability Study16 (currently in progress)


● Vision - STAR, STAR Kids, STAR+PLUS, STAR Health

● Primary Care - STAR, STAR Kids, STAR+PLUS, STAR Health

● Behavioral Health - STAR, STAR Kids, STAR+PLUS, STAR Health

Results

The results of the appointment availability studies show MCOs generally in

compliance with appointment wait time standards for PCPs, but not in compliance

with standards for high-risk prenatal care and behavioral health. However, the

sample size of the study is limited due to the inability to reach many of the

providers included in MCO provider directories. As a result, the study’s finding may

not always be representative of an MCO’s full network of providers.

15 The appointment availability studies also included the CHIP program; however SB760 and

this report do not pertain to CHIP.

16 2018/2019 are the first years that STAR Kids and STAR Health will be included in the

Study.

17 Only the STAR program is included in the prenatal sub study. While there are some

pregnant women in other programs, their numbers are small.

17

The EQRO also noted that provider directory accuracy was an issue, both for

Medicaid members and providers seeking to refer patients. As a result, HHSC is

working with the EQRO to develop additional studies to determine root causes for

the directory inaccuracies, best practices, and appropriate corrective actions for

provider directory maintenance. The EQRO performed a literature review of

provider directory standards but found no nationally recognized standards at this

time.

Primary Care

Table 5 below shows PCP program-level compliance with network access standards

described in HHSC managed care contracts, which state that members must have

access to a PCP: within 90 days for preventive care, within 14 days for routine care,

and within 1 day for urgent care.

Table 5. Program-level Compliance for Primary Care

Program Standard 2015 2016

STAR PCP Child Urgent Care (24 hours) 99.30% 99.60%

STAR PCP Child Routine Care (14 days) 94.90% 89.60%

STAR PCP Child Preventive Care (90 days) 99.80% 99.60%

STAR PCP Adult Urgent Care (24 hours) 97.90% 98.90%

STAR PCP Adult Routine Care (14 days) 85.80% 93.50%

STAR PCP Adult Preventive Care (90 days) 99.40% 97.60%

STAR+PLUS PCP Urgent Care (24 hours) 95.70% 99.10%

STAR+PLUS PCP Routine Care (14 days) 77.20% 87.80%

STAR+PLUS PCP Preventive Care (90 days) 96.80% 97.00%

In addition to recommending HHSC take steps to improve provider directory

accuracy, the EQRO recommends that HHSC encourage MCOs to work with

providers to make weekend appointments available to members to improve access.

18

Only about one-third of providers with available appointments indicated they

offered appointments on weekends.

Behavioral Health18

Table 6 shows program-level compliance with managed care contract requirements

for behavioral health. The contract requires that members must have access to a

behavioral health provider within 14 days. While individual MCO results vary,

overall, access to behavioral health providers in Texas improved across all

programs for 2016. The behavioral health corrective action plan threshold for 2016

was 75 percent for children in STAR, 79 percent for adults in STAR, and 89 percent

for STAR+PLUS.

Table 6. Program-level Compliance for Behavioral Health

Program 2015 2016

STAR - Child 65.40% 77.40%

STAR - Adult 69.40% 76.00%

STAR+PLUS 79.40% 81.70%

Prenatal

The EQRO only performs the prenatal sub-study for the STAR program. Although

other programs have some pregnant members, the numbers are too small to

produce an adequate sample.

For this study, the callers used three separate telephone scripts with specific

scenarios meant to represent members who were: (1) 12 weeks into the pregnancy

(low-risk); (2) about 20 weeks into the pregnancy with a previous diagnosis of

diabetes (high-risk); and (3) 32 weeks into the pregnancy (third trimester). Table 7

describes program-level compliance for access to STAR prenatal service providers in

2016 and 2018. Compliance with the standard increased for both low-risk and

third-trimester appointments, but decreased significantly for high-risk

18 Calls to STAR+PLUS providers in Hurricane Harvey-affected counties were suspended

from August 25 through October 8, 2017, which should inform any interpretation of the

study results.

19

appointments. The corrective action plan threshold for the 2018 study was

85 percent for low-risk prenatal appointments, 51 percent for high-risk prenatal

appointments, and 51 percent for third trimester appointments.

Table 7. Program-level Compliance for STAR Prenatal

Standard 2016 2018

Low-risk: Appointment available

within 14 days

71.4% 72.5%

High-risk: Appointment available

within five days

44.2% 27.9%

Third Trimester: Appointment

available within five days

37.6% 57.9%

Additional research may be necessary to determine why appointments for high-risk

pregnancy continue to exceed prescribed wait times. HHSC will continue

investigating the root cause of these results.

Vision

Table 8 describes program-level compliance with managed care contract

requirements that members must have access to a vision care provider without a

PCP referral. While individual MCO results may vary, access to vision providers

generally improved across all programs from 2015 to 2016. The 2016 corrective

action plan threshold for vision appointments was 99 percent across all programs.

Table 8. Program-level Compliance of Vision Care Providers

Program 2015 2016

STAR 91.40% 92.70%

STAR+PLUS 89.40% 96.10%

Corrective Action Plans

In an effort to promote improvement, HHSC used the results from the 2015

appointment availability study as a baseline to establish CAP thresholds for 2016.

20

Thresholds for the 2016 study were set at ten points above the mean statewide

compliance with wait times in the 2015 study, with a maximum threshold of 99

percent. Table 9 shows the 2015 benchmark and 2016 CAP threshold for each

program and standard.

Table 9. 2016 CAP Thresholds

Program Standard 2015

Benchmark

2016 and

2018 CAP

Thresholds

STAR OBGYN Low-risk (14 Days) 74.9% 85%

STAR OBGYN High-risk (5 days) 40.9% 51%

STAR OBGYN 3rd Trimester (5 days) 40.9% 51%

STAR Behavioral Health Child (14

days)

65.4% 75%

STAR Behavioral Health Adult (14

days)

69.4% 79%

STAR Child Vision (no referral required) 91.4% 99%

STAR PCP Child Urgent Care (24 hours) 99.3% 99%

STAR PCP Child Routine Care (14 days) 94.9% 99%

STAR PCP Child Preventive Care (90

days)

99.8% 99%

STAR PCP Adult Urgent Care (24

hours)

97.9% 99%

STAR PCP Adult Routine Care (14 days) 85.8% 96%

STAR PCP Adult Preventive Care (90

days)

99.4% 99%

21

Program Standard 2015

Benchmark

2016 and

2018 CAP

Thresholds

STAR+PLUS Behavioral Health Adult (14

days)

79.4% 89%

STAR+PLUS Vision (no referral required) 89.4% 99%

STAR+PLUS PCP Urgent Care (24 hours) 95.7% 99%

STAR+PLUS PCP Routine Care (14 days) 77.2% 87%

STAR+PLUS PCP Preventive Care (90 days) 96.8% 99%

Across all programs, each MCO failed to meet the requirements for at least one

provider type. MCOs averaged six CAPs each across all programs, with two being

the lowest, and 11 being the highest number of CAPs for any given MCO.

There are several factors that may affect MCO compliance, including statewide and

national workforce issues19, provider directory accuracy, and the accuracy of

information given by provider staff. At this time, HHSC and the EQRO are working

together to determine appropriate follow-up studies, training, and corrective actions

to address appointment availability.

Corrective Action Plan Responses

In order to address provider network deficiencies identified in the appointment

availability studies, MCOs provided a broad range of proposed actions in their 2016

CAPs, including:

● Provider education in the form of letters, email and fax blasts, trainings and

webinars, and provider orientations;

19 The Department of State Health Services Primary Care Office publishes data on statewide

provider shortages. Additional information, including information on areas deemed Health

Professional Shortage areas can be found here: https://www.dshs.texas.gov/chpr/Health-

Professional-Shortage-Area-Designation.aspx

https://www.dshs.texas.gov/chpr/Health-Professional-Shortage-Area-Designation.aspxhttps://www.dshs.texas.gov/chpr/Health-Professional-Shortage-Area-Designation.aspx

22

● Quality audits including appointment availability studies conducted by the

MCOs;

● Provider outreach calls to assess the accuracy of provider directory

information;

● Online training materials, interactive videos, and review of HHSC provider

manuals; and

● Coordination with MCO corporate offices to ensure provider information is

updated and corrected on a regular basis.

Upon completion of the 2018 appointment availability study, HHSC will identify best

practices and make recommendations for interventions to help all MCOs improve

performance.

Prior Authorization Wait Times

S.B. 760 requires MCOs to report data on the sufficiency of the organization's

provider network with regard to providing care under Texas Government Code

§533.0061(a), including specific data on the average length of time: (1) for

approving or denying a request for prior authorization of services, and (2) between

approving the request and initiation of service.

In fulfillment of this requirement, HHSC requested each MCO provide information

for each program (STAR, STAR Health, STAR Kids, and STAR+PLUS) for the

following services:

● Physician specialty care

● In-home services:

Nursing services

Occupational therapy

Physical therapy

Speech therapy

Attendant care

● Clinic or provider setting

Occupational therapy

Physical therapy

Speech therapy

For each service listed above, HHSC asked each MCO to report on the average

length of time between:

https://statutes.capitol.texas.gov/Docs/GV/htm/GV.533.htmhttps://statutes.capitol.texas.gov/Docs/GV/htm/GV.533.htm

23

● The date a provider requested prior authorization and the date the

authorization is either approved or denied by the MCO, and

● The date authorization is approved and the date service is initiated.

MCO prior authorization reporting results can be found in Appendix B, and are

based on MCO self-reported data for services authorized between March 1, 2018

and May 30, 2018 (fiscal year 2018, Q3). HHSC managed care contracts require

MCOs to issue a determination on prior authorization requests within three business

days of the request. The majority of MCOs reported making a decision on prior

authorization requests, on average, in three days or less, and most MCOs reported

services initiated, on average, within 21 days of authorization.

There are challenges and limitations to the data collected on prior

authorization/service initiation wait times. Variation exists among MCOs in service

authorization requirements for some services, as managed care contracts provide

MCOs flexibility in establishing MCO prior authorization policies. Prior authorization

requirements also vary within an MCO’s network. For example, certain providers

may be exempt from requiring referrals or prior authorizations based on the

provider's history and past performance.

Multiple factors can result in delay between prior authorization approval and service

initiation, including a member not following up with the provider, or the chosen

provider not being available for an appointment. Similarly, a member not being

available for a required assessment could result in delays in an MCO decision on a

prior authorization request. An MCO also could require prior approval for purposes

of claims payment and not service initiation, resulting in receipt of care before the

date of service request or authorization.

HHSC will continue to explore additional methods to capture information and

conduct meaningful analysis on the time it takes for members to obtain services

after prior authorization.

Provider Ratios

S.B 760 requires HHSC to include in its biennial report to the Legislature,

information and statistics on member access, including specific information on

provider-to-recipient ratios in an MCO’s provider network, as well as benchmark

ratios to indicate whether deficiencies exist in a given network. In response to this

legislative requirement, HHSC examined provider-to-member ratios for each MCO,

24

by service area, and county type (metro, micro, and rural), for each Medicaid

managed care program based on fiscal year 2018, Quarter 3 (March 2018 - May

2018) MCO data. See Appendix C for a full report of these ratios.

The Department of State Health Services (DSHS) Health Professional Resource

Center is the primary source of health workforce information in Texas. While data

on all physician specialties and health care provider types are not available, DSHS

does publish data for primary care and psychiatry. Table 10 and Table 11 below

show the ratio for the general population of Texas to one licensed primary care

provider or one psychiatrist. The information reported in Table 10 and Table 11

below is derived from DSHS Supply tables (September 2017) at

http://www.dshs.texas.gov/chs/hprc/health.shtm.

Table 10. Texas Licensed Primary Care Providers: Ratio of 2017 Population to 1

Provider, Statewide and by Service Area, reported by County Type20

Service Area Within Entire

Service Area

in Metro

Counties

in Micro

Counties

in Rural

Counties

Statewide 1,362.1 1,273.0 2,024.0 2,356.8

Bexar 1,319.8 1,268.8 1,568.8 3,164.9

Dallas 1,155.1 1,149.3 NA 1,893.6

El Paso 2,018.7 2,014.7 NA 3,835.0

Harris 1,243.0 1,224.8 17,698.0 2,220.3

Hidalgo 2,085.9 1,985.6 3,034.5 8,615.3

Jefferson 2,151.5 1,685.7 2,803.5 2,802.2

Lubbock 1,544.5 1,382.0 NA 2,498.4

MRSA Central 1,377.6 1,139.6 2,181.2 1,915.3

MRSA

Northeast 1,466.2 963.7 1,941.8 3,431.4

MRSA West 1,341.4 1,218.1 934.8 2,173.5

Nueces 1,331.9 1,023.1 2,990.2 2,482.8

Tarrant 1,926.3 1,935.3 1,780.7 NA

20 Reported data is based on an aggregate of the population in all counties of a given county

type within each service area.

http://www.dshs.texas.gov/chs/hprc/health.shtm

25


Service Area

in Metro

Counties

in Micro

Counties

in Rural

Counties

Travis 1,210.7 1,139.0 3,610.7 1,861.0

Note: 'NA' applies to situations in which a particular county type is not present within the service area.

Table 11.Texas Licensed Psychiatrists: Ratio of 2017 Population to 1 Provider,

Statewide and by Service Area, reported by County Type21


Service Area

in Metro

Counties

in Micro

Counties

in Rural

Counties

Statewide 13,258.4 11,829.1 22,314.1 80,488.8

Bexar 10,782.1 10,254.5 18,826.0 25,952.4

Dallas 10,219.1 10,113.4 NA 53,020.0

El Paso 23,905.8 23,804.9 NA -

Harris 10,750.4 10,536.4 26,547.0 115,457.0

Hidalgo 36,182.5 33,210.5 127,448.0 -

Jefferson 36,371.3 19,386.0 86,910.0 -

Lubbock 22,512.4 17,750.6 NA 174,890.0

MRSA Central 19,085.0 12,760.1 39,989.3 78,206.7

MRSA

Northeast 20,226.1 12,599.0 23,648.0 336,280.0

MRSA West 15,985.4 14,597.2 5,258.3 48,783.6

Nueces 29,408.4 19,839.5 46,348.0 -

Tarrant 26,418.1 26,064.7 34,724.5 NA

Travis 7,558.5 6,810.2 68,603.0 -


HHSC tracks primary care physician and specialist counts based on data reported

by MCOs; however, there are currently no established benchmarks for provider

ratios, or managed care contract requirements for member-to-provider ratios.

21 Reported data is an aggregate of the population in all counties of a given county type

within each service area.

26

Although member-to-provider ratios can illustrate the number of providers available

to members, these ratios are limited in their ability to demonstrate member access.

Table 12 and Table 13 provide information about the ratio of members to one

primary care and to one psychiatrist in Medicaid managed care programs. When

compared to statewide data for the general population, the ratio of providers to

members are generally more favorable for PCPs and Psychiatrists in Medicaid

managed care. Statewide, the ratio of individuals to one PCP is 1:1,362, compared

to a ratio of 1:126 for Medicaid, for all programs, and the ratio of individuals to one

Psychiatrist is 1:13,258, compared to a ratio of 1:2,513 for Medicaid, for all

programs. See Appendix C for ratios for other provider types.

Table 12. Medicaid Managed Care Primary Care Providers: Ratio of 2018Q3

members to 1 Provider, Statewide and by County Type

Medicaid

Managed Care

Program

Within Entire

Service Area

in Metro

Counties

in Micro

Counties

in Rural

Counties

All Programs 126.3 126.3 80.3 85.6

STAR 141 141.9 102.3 93.6

STAR Health 3.6 3.7 3.3 3.3

STAR Kids 8.9 9.4 5.1 4.4

STAR+PLUS 12 11.9 10.7 9.2

Bexar - all

programs

121.6 135.4 27.1 49.7

Dallas - all

programs

111.4 120 NA 31.1

El Paso - all

programs

188.2 192.9 NA 2.3

Harris- all

programs

110.2 113.4 23.7 50.3

Hidalgo- all

programs

149.8 162.2 117.4 26.6

Jefferson- all

programs

14.6 8.4 108.6 85.5

Lubbock- all

programs

46.2 52.7 NA 34.5

27

Medicaid

Managed Care

Program

Within Entire

Service Area

in Metro

Counties

in Micro

Counties

in Rural

Counties

MRSA Central- all

programs

22.2 17.7 14.7 39.1

MRSA Northeast-

all programs

37.1 22.3 64.9 49.9

MRSA West- all

programs

39 26 41.2 60.2

Nueces- all

programs

52.6 44.7 54.8 73.1

Tarrant- all

programs

95.6 99.3 82.3 NA

Travis- all

programs

36.8 36.8 52.1 12.6


Table 13. Medicaid Managed Care Psychiatrists: Ratio of 2018Q3 members to 1

Provider, Statewide and by County Type

Medicaid Managed

Care Program

Within Entire

Service Area

in Metro

Counties

in Micro

Counties

in Rural

Counties

All Programs 2513.3 2244.4 2101 1942.3

STAR 2316.9 2083.8 2349.2 1935.1

STAR Health22 47.8 41.5 84.6 47.2

STAR Kids 140 128.9 146.3 121.7

STAR+PLUS 189.1 164.5 272.9 208.9

Bexar - all programs 1256.4 1347.6 245.1 187.7

Dallas - all programs 1054.1 1106 NA 267.4

El Paso - all programs 2008.4 2007.7 NA -

Harris - all programs 1593.4 1572.6 1107 1432.4

22 Data reported for STAR Health is based on Superior’s SFY 2018 Q2 (December 2017 -

February 2018) provider file. FY2018 Q3 data for psychiatrists was not available.

28

Medicaid Managed

Care Program

Within Entire

Service Area

in Metro

Counties

in Micro

Counties

in Rural

Counties

Hidalgo - all programs 3070.7 4727.4 803.8 197.7

Jefferson - all programs 163.4 90.4 4212.6 2150.1

Lubbock - all programs 1750 1915.6 NA 1957.1

MRSA Central - all

programs

377.5 257.8 312.3 1754.6

MRSA Northeast - all

programs

458.4 208.6 4036.6 6312.6

MRSA West - all

programs

1234.6 1054.5 646.5 1405

Nueces - all programs 1735.2 1365.5 1368.9 2202.6

Tarrant - all programs 1098.5 1090.7 1756.3 NA

Travis - all programs 489.5 430.1 886.4 339.1


MCO Network Analysis

In response to S.B. 760, HHSC amended managed care contracts to include new

minimum provider access standards for travel time and distance for specific

provider types and three county designations. These county designations are based

on population and density, and are based on a modification of county types used by

Medicare.

● Medicare Large Metro and Metro were combined to form HHSC Metro;

● Medicare Micro was used to form HHSC Micro; and

● Medicare Rural and Counties with Extreme Access Considerations (CEAC)

were combined to form HHSC Rural.

29

Distance and Travel Time Standards

HHSC requires MCO provider networks to comply with distance and travel time

standards in accordance with managed care contract requirements (Table 1).23

Travel time and distance standards vary by provider and county type.

Monitoring and Reporting

In March 2017, HHSC implemented a new process for analyzing MCO and DMO

provider network data, designed to improve the accuracy and consistency of

provider network analysis across health and dental plans. While the previous

monitoring process relied solely on MCO-reported data, under the revised process,

MAXIMUS (the HHSC enrollment broker) validates MCO and DMO provider data to

ensure accuracy of certain critical elements of the provider directory. HHSC uses

this data to determine proximity of providers in relation to member residences.

HHSC uses geomapping analysis to determine MCO and DMO compliance with

network distance requirements. If an MCO or DMO does not meet the required

compliance standards, HHSC determines whether a contract remedy is appropriate.

An MCO or DMO may request a special exception when it does not meet the

standards. HHSC may grant exceptions for specific areas that do not have providers

available for contracting, or if the MCO is unable to contract with providers in the

area and has demonstrated reasonable efforts to do so.

Results of Distance Analysis

Figure 1 below shows the percentage of members within the required distance of at

least two PCPs for MCOs, and of at least two main dentists for DMOs. The data

presented is from Q3 fiscal year 2018. Appendices D and E provide details of MCO

compliance with distance and travel time standards for PCPs, main dentists, and

specialty providers by program, provider type, and county. The appendices include

data by MCO and by county for select provider types and populations.

With the implementation of the new travel time and distance standards in March

2017, HHSC established a graduated approach to determining MCO compliance with

23 Initial compliance with updated time and distance standards was based on compliance for

at least 75 percent of members in an MCO’s plan. Effective September 1, 2018, the

compliance threshold increased to 90 percent of the MCO’s membership.

30

contract standards and assessing contract remedies. HHSC began with requiring

that at least 75 percent of an MCO’s or DMO’s members have access to providers

within the required distance or travel time. Effective September 1, 2018, HHSC will

consider contract remedies based on member access to two providers for at least

90 percent of members.

For Q3 of fiscal year 2018, which serves as the basis for data included in this

report, the following compliance thresholds were applied for access to primary care

physicians and specialists:

● PCPs – 75 percent of the members within the required distance of two PCPs

with an open panel; and

● All other providers - 75 percent of members within the required distance of

at least one of each provider type.

Figure 1: Percent STAR Members within distance standards of two primary care

providers SFY 2018 Quarter 3 (March 2018 data)

31

Figure 2: Percent STAR+PLUS Members within distance standards for two primary

care providers SFY 2018 Quarter 3 (March 2018 data)

Figure 3: Percent STAR Health Members within distance standards of two primary


32

Figure 4: Percent STAR Kids Members within distance standards of two primary


Figure 5: Percent Members within distance standards of two main dentists SFY

2018 Quarter 3 (March 2018 data)

33

Appendix D provides the results of analysis for the percent of members within

distance standards of two primary care providers or main dentists. Performance

includes the following highlights:

● STAR: with the exception of rural counties in the El Paso service area, all

MCOs met or exceeded 90 percent of members within the distance standard

of two PCPs;

● STAR+PLUS: with the exception of rural counties in the El Paso and Hidalgo

service areas, all MCOs met or exceeded 90 percent of members within the

distance standard of two PCPs;

● STAR Health: regardless of county type, more than 98 percent of STAR

Health members are within the distance standard of two PCPs;

● STAR Kids: with the exception of rural counties in the El Paso service area,

all MCOs met or exceeded 90 percent of members within the distance

standard of two PCPs; and

● Dental: regardless of county type, more than 99 percent of members are

within the distance standard of two main dentists.

Appendix E depicts the percent of members within distance standards of at least

one specialty care provider. As expected, the highest frequency of non-compliance

occurs in micro and rural counties. The two primary reasons cited for these network

challenges are: a lack of available specialty providers in rural areas (e.g., no

hospital, OB/GYN or ophthalmologist in the county), and providers who are in the

area are not interested in participating in Medicaid managed care.

Limitations

Network reports reflect point-in-time data. While provider enrollment data is

generally consistent over extended periods of time, actual enrollment numbers are

subject to day-to-day fluctuations; and member enrollment data can fluctuate

monthly.

There are also limitations to the data collection and analysis process.24 For

example, providers and members whose addresses cannot be verified and

24 HHSC conducted analysis of MCO compliance with travel time standards in Q4 of 2017

(June 2017 - August 2017) and Q1 of 2018 (September 2018 - November 2018). Based on

34

geocoded, either due to information that is dated, or in some cases incorrectly

recorded, are excluded from analysis. The distance and travel time analysis also

does not capture whether a provider is accepting new patients or has capacity for

existing patients. While the analysis has limitations, it reflects the extent to which

MCOs are able to contract with providers in each county, and is one the many tools

HHSC uses to assess network adequacy.

data from these two quarters, HHSC determined MCO compliance with distance standards is

highly correlated with compliance with travel time standards. If an MCO met or failed to

meet distance standards, nearly 98 percent of the time, they also met or failed to meet the

corresponding travel time requirement. Given the high association of these two data sets,

and in the interest of efficient use of resources, HHSC is not conducting quarterly analysis of

travel time.

35

4. Conclusion

Since the passage of S.B. 760, HHSC has revised and improved MCO network

adequacy requirements and processes for monitoring MCO compliance. New travel

time and distance standards for PCPs and specialty providers became effective in

March 2017, along with revised processes for analyzing and monitoring MCO

compliance with these standards. March 2017 contract amendments also included

enhanced requirements for provider directories and expedited credentialing.

Effective September 2018, HHSC adopted revised standards for LTSS and pharmacy

providers.

HHSC uses a variety of tools to monitor and assess member access to care,

including review of appointment wait times, analysis of out-of-network utilization

and member complaints, and member satisfaction surveys. While none of these

tools alone can effectively ensure provider network adequacy, combined they help

HHSC monitor member access to care and identify areas for improvement.

In August 2018, HHSC began a comprehensive cross-divisional review of network

adequacy for the Medicaid managed care programs, as part of an ongoing effort to

ensure that members have access to a choice of quality health care providers and

services. HHSC is working with stakeholders to develop project plans for a range of

network adequacy initiatives, including:

● Streamlining the Medicaid provider enrollment process to reduce the

enrollment cycle time for providers;

● Identifying process changes to improve the accuracy of MCO provider

directories;

● Enhancing the agency’s provider relations function to support and engage

providers around the state;

● Automating manual processes for monitoring travel time and distance

standards;

● Creating an integrated set of network adequacy measures and centralizing

them in a network adequacy performance dashboard; and

● Exploring enhancing access to care for members in rural and underserved

areas through the use of telemedicine, telehealth, and telemonitoring

services.

Some of these activities were initiated in response to a recent Deloitte report on

Medicaid managed care, which recommended adding new network adequacy

36

measures, integrating reporting strategies, and implementing process efficiencies

for calculating time and distance standards. Other activities were initiated as part of

a coordinated HHSC effort to develop a more efficient, comprehensive approach for

ensuring network adequacy in MCO provider networks.

37

List of Acronyms

Acronym Full Name

CADS Center for Analytics and Decision Support

CAP Corrective Action Plan

DMO Dental Managed Care Organization

DSHS Department of State Health Services

ENT Ear, Nose, and Throat

EQRO External Quality Review Organization

GIS Geographic Information System

HHSC Health and Human Services Commission

MCO Managed Care Organization

MRSA Medicaid Rural Service Area

OB/GYN Obstetrics/Gynecology

PCP Primary Care Provider

S.B. Senate Bill

SDA Service Delivery Area

SFY State Fiscal Year

TDI Texas Department of Insurance

UMCC Uniform Managed Care Contract

A-1

Appendix A. County Designations

Texas Medicaid and

CHIP County

Designations

A-2

Notes:

Data Source: CMS Medicare Advantage

These standards do not apply to pharmacy benefits.

HHSC

County

Type

Medicare

Advantage

County Type

Population Density

Metro Large Metro ≥ 1,000,000 ≥ 1,000/mi²

Metro Large Metro 500,000 – 999,999 ≥ 1,500/mi²

Metro Large Metro Any ≥ 5,000/mi²

Metro Large Metro ≥ 1,000,000 10 – 999.9/mi²

Metro Large Metro 500,000 – 999,999 10 – 1,499.9/mi²



Metro Large Metro 10,000 – 49,999 1,000 – 4,999.9/mi²

Micro Micro 50,000 – 199,999 10 – 99.9 /mi²

Micro Micro 10,000 – 49,999 50 – 999.9/mi²

Rural Rural 10,000 – 49,999 10 – 49.9/mi²

Rural Rural

A-3

Designation Counties

Metro Angelina, Bell, Bexar, Bowie, Brazoria, Brazos, Cameron, Collin,

Comal, Dallas, Denton, Ector, El Paso, Ellis, Fort Bend, Galveston,

Grayson, Gregg, Guadalupe, Harris, Hays, Hidalgo, Hood, Hunt,

Jefferson, Johnson, Kaufman, Lubbock, McLennan, Midland,

Montgomery, Nueces, Orange, Parker, Potter, Randall, Rockwall,

Smith, Tarrant, Taylor, Travis, Victoria, Webb, Wichita, Williamson

Micro Anderson, Aransas, Bastrop, Caldwell, Camp, Chambers,

Cherokee, Coryell, Hardin, Harrison, Henderson, Kendall, Kerr,

Lamar, Liberty, Maverick, Morris, Nacogdoches, Rusk, San Patricio,

Starr, Titus, Tom Green, Upshur, Van Zandt, Walker, Waller,

Washington, Wilson, Wise, Wood

Rural Andrews, Archer, Armstrong, Atascosa, Austin, Bailey, Bandera,

Baylor, Bee, Blanco, Borden, Bosque, Brewster, Briscoe, Brooks,

Brown, Burleson, Burnet, Calhoun, Callahan, Carson, Cass, Castro,

Childress, Clay, Cochran, Coke, Coleman, Collingsworth, Colorado,

Comanche, Concho, Cooke, Cottle, Crane, Crockett, Crosby,

Culberson, Dallam, Dawson, Deaf Smith, Delta, DeWitt, Dickens,

Dimmit, Donley, Duval, Eastland, Edwards, Erath, Falls, Fannin,

Fayette, Fisher, Floyd, Foard, Franklin, Freestone, Frio, Gaines,

Garza, Gillespie, Glasscock, Goliad, Gonzales, Gray, Grimes, Hale,

Hall, Hamilton, Hansford, Hardeman, Hartley, Haskell, Hemphill,

Hill, Hockley, Hopkins, Houston, Howard, Hudspeth, Hutchinson,

Irion, Jack, Jackson, Jasper, Jeff Davis, Jim Hogg, Jim Wells,

Jones, Karnes, Kenedy, Kent, Kimble, King, Kinney, Kleberg, Knox,

La Salle, Lamb, Lampasas, Lavaca, Lee, Leon, Limestone,

Lipscomb, Live Oak, Llano, Loving, Lynn, Madison, Marion, Martin,

Mason, Matagorda, McCulloch, McMullen, Medina, Menard, Milam,

Mills, Mitchell, Montague, Moore, Motley, Navarro, Newton, Nolan,

Ochiltree, Oldham, Palo Pinto, Panola, Parmer, Pecos, Polk,

Presidio, Rains, Reagan, Real, Red River, Reeves, Refugio,

Roberts, Robertson, Runnels, Sabine, San Augustine, San Jacinto,

San Saba, Schleicher, Scurry, Shackelford, Shelby, Sherman,

Somervell, Stephens, Sterling, Stonewall, Sutton, Swisher, Terrell,

Terry, Throckmorton, Trinity, Tyler, Upton, Uvalde, Val Verde,

Ward, Wharton, Wheeler, Wilbarger, Willacy, Winkler, Yoakum,

Young, Zapata, Zavala

Notes

The County Designations in Appendix A are for purposes of assessing access to network providers (excluding pharmacies). The designations build upon CMS Medicare Advantage (MA) designations. The table above lists the population and density parameters applied to county

A-4

type designations. A county must meet both thresholds for inclusion in a given designation. In order to facilitate monitoring, HHSC has combined the Large Metro and Metro MA categories into one category for Metro. The categories for Counties with Extreme Access Considerations (CEAC) and Rural counties have been combined to create the Rural category.

B-1

Appendix B. MCO Prior Authorization

Reporting

Each of the tables in this Appendix present the average number of days between a

request for authorization of a service, and the average number of days between the

decision and receipt of the authorized service, reported by MCO, program, and type

of service.

Data is self-reported by MCO for authorization requests received March - May 2018.

Averages are rounded to nearest whole number. Average time for MCOs decisions

can be impacted by incomplete authorization requests or delays in completing

required evaluations to determine medical need. Negative numbers reflect services

which were initiated prior to receipt of authorization request or MCO decision. MCOs

are provided flexibility to determine if a service will require prior authorization. If an

MCO does not require prior authorization, the table shows “not applicable.”

Aetna

Program and Type of Service Authorization

Request to MCO

Decision

MCO Decision to

Service

Initiation

STAR

At-provider occupational therapy 1 14

At-provider physical therapy 1 11

At-provider speech therapy 1 16

In-home attendant care 0 0

In-home nursing 1 8

In-home occupational therapy 1 14

In-home physical therapy 1 11

In-home speech therapy 1 11

Physician specialty care 1 11

STAR Kids



B-2


Request to MCO

Decision

MCO Decision to

Service

Initiation



In-home nursing 2 11





Amerigroup


Request to MCO

Decision

MCO Decision to

Service

Initiation

STAR





In-home nursing 0 0





STAR Kids





B-3


Request to MCO

Decision

MCO Decision to

Service

Initiation

In-home nursing 0 0





STAR+PLUS










Blue Cross and Blue Shield


Request to MCO

Decision

MCO Decision to

Service

Initiation

STAR





In-home nursing 0 0



B-4


Request to MCO

Decision

MCO Decision to

Service

Initiation



STAR Kids










Children’s Medical Center


Request to MCO

Decision

MCO Decision to

Service

Initiation

STAR Kids




In-home attendant care -1 2

In-home nursing 8 8





B-5

Cigna-HealthSpring


Request to MCO

Decision

MCO Decision to

Service

Initiation

STAR+PLUS





In-home nursing 1 2





Community First Health Plans


Request to MCO

Decision

MCO Decision to

Service

Initiation

STAR





In-home nursing 5 8





B-6


Request to MCO

Decision

MCO Decision to

Service

Initiation

STAR Kids










Community Health Choice


Request to MCO

Decision

MCO Decision to

Service

Initiation

STAR





In-home nursing 2 6





B-7

Cook Children’s Health Plan


Request to MCO

Decision

MCO Decision to

Service

Initiation

STAR




In-home attendant care Not Applicable Not Applicable

In-home nursing 4 2




Physician specialty care Not Applicable Not Applicable

STAR Kids





In-home nursing 4 5





Dell Children’s Health Plan


Request to MCO

Decision

MCO Decision to

Service

Initiation

STAR

B-8


Request to MCO

Decision

MCO Decision to

Service

Initiation





In-home nursing 0 0





Driscoll Health Plan


Request to MCO

Decision

MCO Decision to

Service

Initiation

STAR










B-9

El Paso Health


Request to MCO

Decision

MCO Decision to

Service

Initiation

STAR





In-home nursing 3 0





FirstCare


Request to MCO

Decision

MCO Decision to

Service

Initiation

STAR










B-10

Molina Health Care


Request to MCO

Decision

MCO Decision to

Service

Initiation

STAR





In-home nursing 3 5





STAR+PLUS





In-home nursing 3 3





Parkland HEALTHfirst


Request to MCO

Decision

MCO Decision to

Service

Initiation

STAR

B-11


Request to MCO

Decision

MCO Decision to

Service

Initiation





In-home nursing 1 9





Right Care from Scott and White


Request to MCO

Decision

MCO Decision to

Service

Initiation

STAR





In-home nursing 2 2





B-12

Superior HealthPlan


Request to MCO

Decision

MCO Decision to

Service

Initiation

STAR





In-home nursing 5 5





STAR Health





In-home nursing 7 6





STAR Kids





In-home nursing 7 5

B-13


Request to MCO

Decision

MCO Decision to

Service

Initiation





STAR+PLUS





In-home nursing 3 6





Texas Children’s Health Plan


Request to MCO

Decision

MCO Decision to

Service

Initiation

STAR




In-home attendant care 0 -2

In-home nursing 5 -2



B-14


Request to MCO

Decision

MCO Decision to

Service

Initiation


Physician specialty care 3 -1

STAR Kids





In-home nursing 2 1





United HealthCare Community Plan


Request to MCO

Decision

MCO Decision to

Service

Initiation

STAR





In-home nursing 1 1





B-15


Request to MCO

Decision

MCO Decision to

Service

Initiation

STAR Kids





In-home nursing 0 -1





STAR+PLUS


At-provider physical therap

Date post:	02-Oct-2020
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